04040124 CITY OF CUPERTINO
BUILDING DtvISION PERMIT XONTRACTOR INFO,,RMATHON
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BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N`04040124
357 METEOR DR
OWNER'S NAME: PERMIT ISSUE DATE
CHARLES BOLSTER 1764 NATIONAL AVE4 20 2004
ONE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
X00 LICENSED CONTRACTOR'S DECLARATION - U {�
Ev C I hereby arm rothat]am licensed under provisions of Chapter 9(commencing Job DCSCrIpt1O❑
�]a6 with Seclimn](l(X))nf Division Sof the Business and Professions Cndc.end myliwnsc is ^®
AO
in rase mretand erreeh REPLACE WATER HEATER MAY /10- n
License Class Lit.kZOO
e r❑ Datc Contractor (4 0 GAL)
ARCHITECTS DECLARATION
I understand my plans shall he used as public meards peg@ YI�
oto Licensed Pasressinnal
g OWNER-BUILDER DECLARATION
.a I I hereby affirm that 1 am exempt from the Contractor's License Law for the ECOo following mason.(Section](131.5.Business and Professions Code:Any city or County
k m which rC,uirCa a permit In construct,altce improve,demolleh,or repair any stommor
,zaprior to ins issuance.also requires the applicant for such permit to file a signed statement
that he isIice road pursuanttothe PdrVmonsofthe Contractor''sLicense law(Chaper9 Sq. Ft. Floor Area
HValua[it$7740
� (commencing with Section Toil M Division 3 of the B rearosom Professions Cn C
e
i
that he is exempt therefrom and the basis for On alleged exemption.Any vinlminn of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more than five hundred dollars(S500). 32643006 . 00 p y YP
I]1,c owner of the property,or my employees with wages as their sale compensation,
will do the work,and the stroctme is not intended or offered former(Sec.7044,Business
and Professions Code:The Conuecmri License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended oroRered forsale.If,
however,Ne building or improvement is sold within one year of Completion,the owner.
builder will have the burden of proving Nat he did not build or improve fur purpose of
sale.).
❑ 1.as owner of the properly,am exclusively contracting with licensed contractors to
eo marect the project(Sec.70744,Business and professions Codc)The Contractor's Li
cense law does not apply to an owner of property who builds or improves Hereon,and
who contracts for such projects with a contractm(s7 licensed pursuant to the Contractor's
Liecnse Law.
❑1 am exempt under Sec. .B&P C for this recon
Owner Dee
WORKER'S COMPENSATION DECLARATION
1 hereby offum under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insumfor Worker's Comped-
nation,as provided for by Section 3700 of the Lhor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,se required by Section
3700.1 the Labor Code,for the performance of the work far which his proud is issued
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed Rose permit is for one hundred dollars(5100)
nr Icas.)
I certify that in the performance of the work for which this permit Is issued,1 shall not
employ any person in any manner ser c m become subject to the Workers'Compensation -
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Ce uricale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall he deemed revoked.
zt q CONSTRUCTION LENDING AGENCY
4 I hereby affirm Beat there is a corourat ion lending agency for the performance of a'L
y'> the work for which this permit is issued(Sec.3097,Co.C.)
W� Q Lender's Name
z Lender's Address
U Q 1 certify that 1 have mad this application and one that the above information is
(T. F codecs 1 agree to comply with all city and county ordinances and state laws relating to
Q U building construction.and hereby outh Tint representatives of Nis city to enter upon the -
H Cahmve-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
p7 liabilities,judgments,costs and expenses which may in any way accme against said City
U z in consequence of the grand ng of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaHDa
HAZARDOUS
m US MATERIALS DISCLOSURE Type of Roof
Will the applicant serfuture building occupant store m handle Heals and Safety c Code by the Cupertino Municipal,Code.Chaper 9.12.and the Health and Safety
edge,noetics 2ss3zca77
El Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Ureupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants c dcfincd by the Bay Area Air Quality Management all new materials for inspection.
7D,,tict?❑Yes ❑No
I have mad the hmardle s materials requirements under Chapter 6.95 o(the Callar.
HcaW&SafcryCalc,Stemmas 35505.25533 and 25534.1 undcrsend that ifthc building
s nor cumemly have a tennt,that itis my reeponsmility In n rely the Occupant of the
uiemcnts which must at met prior it)issuance of a Cemrcas of acupancy. Signature of Applicant Date
Owner or authorized agent Data All roof coverings to be Class "B" or better
Community Development
10300 Torte Avenue
-'W
Cupertino CA 95014
Telephone(408)777-3228.
OCITY OF Fax(408)777-3333
UPER,TINO
Building Department
JOB ADDRESS: PERMIT #
21357 Meteor Dr, a,1 - " C L "
OWNER'S NAME: Bolster, Charles PHONE #408-746-0851
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: D-"� �-i 4/19/04
Signature Date
Please check applicable subcontractors and complete the following information:
21 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
. Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing Just Water Heaters 591329
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
�'�`>.�S' 1•-�o•�c�Qx�v`--� 4/19/04
Owner/Contractor Signature Date
10/28/03
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 21357 Meteor Dr. Date: 4-19-04
Owner's Name:---Bolster,Charles
Phone No.(408)746-0851
APN#: 326-43-006 Project Valuation: S 740.00
Building Permit Info: Bldg_—_ Elect__---_ Plumb----—X----- Mech___—______
Job Description
Replace 40 gal water heater
Contractor Information
• Company: Just Water Heaters Inc. Phone: (510)293-2012
Contact Name: Dulce Fax: (510)293-2022
Address: 1764 National Ave. E-mail: permits@Justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State contractor's License# 591 329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-03 Carrier:State Compensation Insurance Fund Exp. Date: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: Just Water Heaters Inc. 6� (�
Expiration Date: 9/05
Visa MasterCard X
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